Basic Information
| Provider Information | |||||||||
| NPI: | 1457337834 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL OREGON PEDIATRIC ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 NE PROFESSIONAL CT | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413896313 | ||||||||
| FaxNumber: | 5413898760 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 NE PROFESSIONAL CT | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413896313 | ||||||||
| FaxNumber: | 5413898760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 11/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | WADE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5413896313 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.